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General NPI Number Information
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NPI Number | 1730337114
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Entity Type | Organization
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Legal Business Name | FULL POTENTIAL RESIDENTIAL SERVICES, LLC
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Dates
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Enumeration Date | 08/28/2008
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Last Update Date | 08/28/2008
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Provider Practice Location Address
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Address Line | 8208 PAGE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63130-1115
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Country | US
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Telephone | 314-839-9157
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Fax | 314-839-9157
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Provider Business Mailing Address
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Address Line | 2335 INDIANCUP DR
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City | FLORISSANT
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State | MO
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Zip | 63033-1736
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Country | US
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Telephone | 314-839-9157
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. DEMETRA EVON ROBERTS
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Credential | LIC. SOCIAL WORKER
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Telephone | 314-839-9157
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 2006031224
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License Number State | MO
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